Hypoglycemia in Individuals Self-Managing Diabetes With CGMs
Hypoglycemia is a common yet high-risk complication among individuals with diabetes. While recent advancements in diabetes technologies have helped patients and providers better prevent and manage hypoglycemic events, challenges persist among patients who self-manage hypoglycemia.
To better understand aspects relating to hypoglycemic self-management in patients with type 1 diabetes who utilize these technologies, researchers conducted a qualitative study interviewing this patient population to examine factors and experiences that play a role in the development of hypoglycemia.
To discuss the results of this research, Consultant360 reached out to the lead study author, Yu Kuei (Alex) Lin, MD. Dr Lin is a Clinical Associate Professor of Internal Medicine in the Division of Metabolism, Endocrinology & Diabetes at the University of Michigan and Elizabeth Weiser Caswell Diabetes Institute in Ann Arbor, MI.
Consultant360: To begin, could you discuss what prompted this research? Why now?
Alex Lin: Our recent studies, along with those conducted by others, have revealed that approximately a quarter of individuals living with type 1 diabetes continue to experience hypoglycemia despite utilizing advanced diabetes technologies such as continuous glucose monitors (CGMs) or automated insulin delivery devices. Emerging evidence suggests that impaired awareness of hypoglycemia and the presence of unhelpful hypoglycemia beliefs are associated with heightened risks of hypoglycemia in this population. However, additional information was needed to (1) contextualize how these risk factors contribute to hypoglycemia development and evaluate whether other factors are involved; and (2) guide the development of new interventions or the adaptation of existing interventions to address these conditions to ultimately minimize hypoglycemia. This study was timely as these novel diabetes technologies have become standard care, yet the ongoing problem of hypoglycemia persists, now involving health beliefs, behavioral factors, and beyond.
C360: Your study notes that 39% of the study participants had an impaired awareness of hypoglycemia. What are some interventions health care providers can utilize to better inform patients using these diabetes technologies of hypoglycemia?
AL: Quality improvement initiatives such as the T1D Exchange Quality Improvement Collaborative have been instrumental in increasing access to CGMs and addressing barriers to their utilization. These efforts have led to a significant increase in CGM usage. However, despite these advancements, disparities in the adoption of CGM technologies still persist. Ongoing research is crucial for identifying the specific areas and methods to address these gaps effectively.
It is worth noting that our study intentionally recruited individuals who continue to experience hypoglycemia despite using CGMs. As a result, the prevalence of impaired awareness of hypoglycemia appears to be higher in our study compared with other recent epidemiological studies.
C360: Many participants of your study expressed the need for both hypoglycemia symptoms in addition to CGM hypoglycemia data before they took management actions for hypoglycemia. How might symptoms of hypoglycemia vary from person to person, and how does hypoglycemia severity impact symptoms?
AL: Previous research has indicated that older age, longer duration of diabetes, and female sex are associated with experiencing fewer hypoglycemia symptoms. However, in addition to inter-individual differences, another challenge lies in the fact that symptoms can fluctuate on a day-to-day basis depending on the timing, proximity, and severity of recent hypoglycemic events. For instance, a single hypoglycemic episode with a glucose level below 54 mg/dL lasting for more than 5 to 30 minutes has been shown to significantly reduce hypoglycemic symptoms in the subsequent 24 hours. Additionally, factors such as alcohol use, sleep patterns, and exercise levels may also impact hypoglycemia awareness.
C360: Can you discuss how a better understanding of the barriers and experiences patients face, such as a fear of rebound hyperglycemia or social support and stigma, may influence how patient-provider teams utilize CGMs to self-manage hypoglycemia?
AL: We believe that additional interventions are necessary to address the complex issues surrounding hypoglycemia management in people using CGMs. Recently, the HARPdoc intervention has shown promise in addressing unhelpful hypoglycemia beliefs and reducing severe hypoglycemia in individuals who continue to experience hypoglycemia despite having access to CGM technologies. In addition to individual-level interventions, addressing social stigma associated with hypoglycemia may require multi-level approaches. These interventions could focus on improving comfort levels in self-managing hypoglycemia in public settings while raising societal awareness and knowledge about hypoglycemia and diabetes.
It is important to note that as most individuals using CGMs do not encounter problematic hypoglycemia, interventions should be targeted towards those who continue to experience hypoglycemia despite utilizing diabetes technologies. By focusing efforts on this subgroup, we can better tailor interventions to meet their specific needs and ultimately improve their health and quality of life.
C360: What knowledge gaps remain on hypoglycemia self-management in patients using CGMs?
AL: We acknowledge several knowledge gaps that persist in our understanding of hypoglycemia self-management among CGM users. While our study has begun to shed light on the social barriers to hypoglycemia self-management in this population, additional follow-up research is warranted. Studies involving individuals living with diabetes, as well as their friends and family members, are needed to contextualize their experiences and identify any gaps in knowledge and communication that may exist. Furthermore, needs in interventions targeting impaired awareness of hypoglycemia, unhelpful hypoglycemia beliefs, and social barriers must not only be effective but also widely accessible and personalized. This approach is crucial to minimize the burden on the health care system while ensuring that individuals receive tailored support to manage their condition effectively. Lastly, our study focused exclusively on adults, and the challenges associated with managing hypoglycemia in children and adolescents remain to be elucidated. Future research efforts should aim to address these gaps in knowledge to ensure comprehensive care for individuals across all age groups living with diabetes.
Reference:
Lin YK, Agni A, Chuisano S, et al. ‘You have to use everything and come to some equilibrium’: a qualitative study on hypoglycemia self-management in users of continuous glucose monitor with diverse hypoglycemia experiences. BMJ Open Diabetes Res Care. 2023;11:e003415. doi:10.1136/bmjdrc-2023-003415.